Method and apparatus for modifications of visual acuity by thermal means

ABSTRACT

A thermokeratoplasty system and method for locally heating and reshaping a cornea in a manner that produces a minimal regression of the corneal correction. The system includes a probe that is coupled to a power source which can provide a predetermined power, frequency and time duration that creates a thermal profile within the cornea which extends from the epithelium into the corneal stroma. The electrical return of the probe is a lid speculum which maintains the eye lids in an open position. The probe is placed into contact with the cornea and energy is transferred from the power source to the eye, through the lid speculum and back to the power source. The energy from the power supply is focused by a probe tip that locally heats and denatures the cornea, and causes a subsequent shrinkage of corneal tissue. A pattern of denatured areas can be created around the cornea to correct the vision of the eye. It has been found that power no greater than 1.2 watts, for a duration no greater than 1.0 seconds, will sufficiently induce corneal shrinkage without significant regression of the visual acuity correction of the eye. The probe may have an electronic circuit which prevents usage of the probe after a predetermined number of procedures.

CROSS-REFERENCES TO RELATED APPLICATIONS

The above-entitled patent application is a continuation-in-part ofapplication Ser. No. 08/171,255, filed on Dec. 20, 1993, pending, whichis a continuation-in-part of application Ser. No. 08/111,296, filed onAug. 23, 1993, which issued as U.S. Pat. No. 5,523,999 on Jul. 9, 1996.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to a thermokeratoplasty probe that isplaced into direct contact with the outer surface of the cornea.

2. Description of Related Art

Techniques for correcting vision have included reshaping the cornea ofthe eye. For example, myopic conditions can be corrected by cutting anumber of small incisions in the corneal membrane. The incisions allowthe corneal membrane to relax and increase the radius of the cornea. Theincisions are typically created with either a laser or a precisionknife. The procedure for creating incisions to correct myopic defects iscommonly referred to as radial keratotomy and is well known in the art.

Present radial keratotomy techniques generally make incisions thatpenetrate approximately 95% of the cornea. Penetrating the cornea tosuch a depth increases the risk of puncturing the decemets membrane andthe endothelium layer, and creating permanent damage to the eye.Additionally, light entering the cornea at the incision sight isrefracted by the incision scar and produces a glaring effect in thevisual field. The glare effect of the scar produces impaired nightvision for the patient. It would be desirable to have a procedure forcorrecting myopia that does not require a 95% penetration of the cornea.

The techniques of radial keratotomy are only effective in correctingmyopia. Radial keratotomy cannot be used to correct an eye conditionsuch as hyperopia. Additionally, keratotomy has limited use in reducingor correcting an astigmatism. The cornea of a patient with hyperopia isrelatively flat (large spherical radius). A flat cornea creates a lenssystem which does not correctly focus the viewed image onto the retinaof the eye. Hyperopia can be corrected by reshaping the eye to decreasethe spherical radius of the cornea. It has been found that hyperopia canbe corrected by heating and denaturing local regions of the cornea. Thedenatured tissue contracts and changes the shape of the cornea andcorrects the optical characteristics of the eye. The procedure ofheating the corneal membrane to correct a patient's vision is commonlyreferred to as thermokeratoplasty.

U.S. Pat. No. 4,461,294 issued to Baron; U.S. Pat. No. 4,976,709 issuedto Sand and PCT Publication WO 90/12618, all disclosethermokeratoplastic techniques which utilize a laser to heat the cornea.The energy of the laser generates localized heat within the cornealstroma through photonic absorption. The heated areas of the stroma thenshrink to change the shape of the eye.

Although effective in reshaping the eye, the laser based systems of theBaron, Sand and PCT references are relatively expensive to produce, havea non-uniform thermal conduction profile, are not self limiting, aresusceptible to providing too much heat to the eye, may induceastigmatism and produce excessive adjacent tissue damage, and requirelong term stabilization of the eye. Expensive laser systems increase thecost of the procedure and are economically impractical to gainwidespread market acceptance and use. Additionally, laserthermokeratoplastic techniques non-uniformly shrink the stroma withoutshrinking the Bowmans layer. Shrinking the stroma without acorresponding shrinkage of the Bowmans layer, creates a mechanicalstrain in the cornea. The mechanical strain may produce an undesirablereshaping of the cornea and probable regression of the visual acuitycorrection as the corneal lesion heals. Laser techniques may alsoperforate Bowmans layer and leave a leucoma within the visual field ofthe eye.

U.S. Pat. Nos. 4,326,529 and 4,381,007 issued to Doss et al, discloseelectrodes that are used to heat large areas of the cornea to correctfor myopia. The electrode is located within a housing that spaces thetip of the electrode from the surface of the eye. An isotropic salinesolution is irrigated through the electrode and aspirated through achannel formed between the outer surface of the electrode and the innersurface of the sleeve. The saline solution provides an electricallyconductive medium between the electrode and the corneal membrane. Thecurrent from the electrode heats the outer layers of the cornea. Heatingthe outer eye tissue causes the cornea to shrink into a new radialshape. The saline solution also functions as a coolant which cools theouter epithelium layer.

The saline solution of the Doss device spreads the current of theelectrode over a relatively large area of the cornea. Consequently,thermokeratoplasty techniques using the Doss device are limited toreshaped corneas with relatively large and undesirable denatured areaswithin the visual axis of the eye. The electrode device of the Dosssystem is also relatively complex and cumbersome to use.

"A Technique for the Selective Heating of Corneal Stroma" Doss et al.,Contact & Intraoccular Lens Medical Jrl., Vol. 6, No. 1, pp. 13-17,January-March, 1980, discusses a procedure wherein the circulatingsaline electrode (CSE) of the Doss patent was used to heat a pig cornea.The electrode provided 30 volts r.m.s. of power for 4 seconds. Theresults showed that the stroma was heated to 70° C. and the Bowman'smembrane was heated 45° C., a temperature below the 50°-55° C. requiredto shrink the cornea without regression.

"The Need For Prompt Prospective Investigation" McDonnell, Refractive &Corneal Surgery, Vol. 5, January/February, 1989 discusses the merits ofcorneal reshaping by thermokeratoplasty techniques. The articlediscusses a procedure wherein a stromal collagen was heated by radiofrequency waves to correct for a keratoconus condition. As the articlereports, the patient had an initial profound flattening of the eyefollowed by significant regression within weeks of the procedure.

"Regression of Effect Following Radial Thermokeratoplasty in Humans"Feldman et al., Refractive and Corneal Surgery, Vol. 5,September/October, 1989, discusses another thermokeratoplasty techniquefor correcting hyperopia. Feldman inserted a probe into four differentlocations of the cornea. The probe was heated to 600° C. and wasinserted into the cornea for 0.3 seconds. Like the procedure discussedin the McDonnell article, the Feldman technique initially reducedhyperopia, but the patients had a significant regression within 9 monthsof the procedure. To date, there has been no published findings of athermokeratoplasty technique that will predictably reshape and correctthe vision of a cornea without a significant regression of the cornealcorrection.

It would therefore be desirable to provide a thermokeratoplastytechnique which can predictably reshape and correct the vision of an eyewithout a significant regression of the visual acuity correction.

Electrodes are subject to contamination, when RF electrical current isused for thermokeratoplasty. For example, an electrolized layer orprotein film may form on the surface of the electrodes. Such a film mayvary the impedance of the electrodes and affect the performance of theinstrument. Varying instrument performance may create inconsistentresults. Therefore it would be desirable to provide athermokeratoplastic probe that would have to be replaced by a new deviceafter a predetermined number of uses.

SUMMARY OF THE INVENTION

The present invention is a thermokeratoplasty system and method forlocally heating and reshaping a cornea in a manner that produces aminimal regression of the corneal correction. The system includes aprobe that is coupled to a power source which can provide apredetermined power, frequency and time duration that creates a thermalprofile within the cornea which extends from the epithelium into thecorneal stroma. The electrical return of the probe is a lid speculumwhich maintains the eye lids in an open position. The probe is placedinto contact with the cornea and energy is transferred from the powersource to the eye, through the lid speculum and back to the powersource. The energy from the power supply is focused by a probe tip thatlocally heats and denatures the cornea, and causes a subsequentshrinkage of corneal tissue. A pattern of denatured areas can be createdaround the cornea to correct the vision of the eye. It has been foundthat power no greater than 1.2 watts, for a duration no greater than 1.0seconds, will sufficiently induce corneal shrinkage without anysignificant regression of the visual acuity correction of the eye. Theprobe may have an electronic circuit which prevents usage of the probeafter a predetermined number of procedures.

BRIEF DESCRIPTION OF THE DRAWINGS

The objects and advantages of the present invention will become morereadily apparent to those ordinarily skilled in the art after reviewingthe following detailed description and accompanying drawings, wherein:

FIG. 1 a perspective view of a thermokeratoplastic electrode system ofthe present invention;

FIG. 1a is a graph showing a waveform that is provided to the probe ofthe system;

FIG. 1b is a graph showing the amount of typical vision correctionregression over time;

FIG. 1c is a representation of a nominal thermal profile within thecornea produced by the electrode system of the present invention;

FIG. 2 is a top view of an electrode probe of the system;

FIG. 3 is a side view of the probe in FIG. 2;

FIG. 4 is an enlarged view of the probe tip;

FIG. 5 is a side view showing the probe being used to treat an area ofthe corneal membrane;

FIG. 6 is a top view showing a pattern of denatured areas of the cornea;

FIG. 7 is a perspective view of an alternate embodiment of the probe;

FIGS. 8a-b show a method for performing a procedure of the presentinvention;

FIG. 9 shows a pattern of incisions and denatured areas to correct for amyopic condition;

FIG. 10 shows another pattern of incisions and denatured areas tocorrect for hyperopic conditions;

FIG. 11 shows a preferred embodiment of the present invention;

FIG. 11a is an enlarged view of the tip of FIG. 11;

FIG. 12 is a perspective view of a probe with the return electrode as alid speculum that maintains the eye lid in an open position;

FIG. 13 is a side view of an alternate probe tip embodiment;

FIG. 14 is a side view of an alternate probe tip embodiment;

FIG. 15 is a side view of an alternate probe tip embodiment;

FIG. 16 is a side view of an alternate probe tip embodiment;

FIG. 17 is a side view of an alternate probe tip embodiment;

FIG. 18 is a side view of an alternate probe embodiment;

FIG. 19 is a schematic of a circuit which limits the use of a probebeyond a predetermined useful life.

DETAILED DESCRIPTION OF THE INVENTION

Referring to the drawings more particularly by reference numbers, FIG. 1shows a thermokeratoplastic electrode system 10 of the presentinvention. The system 10 includes an electrode probe 12 coupled to apower supply unit 14. The power supply unit 14 contains a power supplywhich can deliver power to the probe 12. The probe 12 has a hand piece16 and wires 18 that couple the probe electrodes to a connector 20 thatplugs into a mating receptacle 22 located on the front panel 24 of thepower unit. The hand piece 16 may be constructed from a non-conductivematerial and is approximately 0.5 inches in diameter and 5 inches long.

The power supply 14 provides a predetermined amount of energy, through acontrolled application of power for a predetermined time duration. Thepower supply 14 may have manual controls that allow the user to selecttreatment parameters such as the power and time duration. The powersupply 14 can also be constructed to provide an automated operation. Thesupply 14 may have monitors and feedback systems for measuring tissueimpedance, tissue temperature and other parameters, and adjust theoutput power of the supply to accomplish the desired results. The unitmay also have a display that indicates the number of remaining usesavailable for the probe 12.

In the preferred embodiment, the power supply provides a constantcurrent source and voltage limiting to prevent arcing. To protect thepatient from overvoltage or overpower, the power unit 14 may have anupper voltage limit and/or upper power limit which terminates power tothe probe when the output voltage or power of the unit exceeds apredetermined value. The power unit 14 may also contain monitor andalarm circuits which monitor the resistance or impedance of the load andprovide an alarm when the resistance/impedance value exceeds and/orfalls below predefined limits. The alarm may provide either an audioand/or visual indication to the user that the resistance/impedance valuehas exceeded the outer predefined limits. Additionally, the unit maycontain a ground fault indicator, and/or a tissue temperature monitor.The front panel of the power unit typically contains meters and displaysthat provide an indication of the power, frequency, etc., of the powerdelivered to the probe.

The power unit 14 may deliver a power output in a frequency range of 5KHz-50 MHz. In the preferred embodiment, power is provided to the probeat a frequency in the range of 500 KHz. The unit 14 is designed so thatthe power supplied to the probe 12 does not exceed 1.2 watts (W). Thetime duration of each application of power to a particular corneallocation is typically between 0.1-1.0 seconds. The unit 14 is preferablyset to deliver approximately 0.75 W of power for 0.75 seconds. FIG. 1ashows a typical voltage waveform that is applied by the unit 14. Eachpulse of energy delivered by the unit 14 is a highly damped signal,typically having a crest factor (peak voltage/RMS voltage) greater than10:1. Each power dissipation is provided at a repetitive rate. Therepetitive rate may range between 4-12 KHz and is preferably set at 8KHz.

The system has a switch which controls the application of power to theprobe 12. The power unit 14 also contains a timer circuit which allowspower to be supplied to the probe 12 for a precise predetermined timeinterval. The timer may be a Dose timer or other similar conventionalcircuitry which terminates power to the probe after a predetermined timeinterval. The unit may also allow the user to apply power until theswitch is released. As one embodiment, the power supply may be a unitsold by Birtcher Medical Co. under the trademark HYFRECATOR PLUS, Model7-797 which is modified to have voltage, waveform, time durations andpower limits to comply with the above cited specifications.

The power unit 14 may have a control member 26 to allow the user toselect between a "uni-polar" or a "bi-polar" operation. The power supply14 may be constructed to provide a single range of numerical settings,whereupon the appropriate output power, time duration and repetitionrate are determined by the hardware and software of the unit. The frontpanel of the power unit may also have control members (not shown) thatallow the surgeon to vary the power, frequency, timer interval, etc. ofthe unit. The return electrode (not shown) for a uni-polar probe may becoupled to the power unit through a connector located on the unit. Thereturn electrode is preferably a cylindrical bar that is held by thepatient, or an eye fixation electrode.

It has been found that at higher diopters, effective results can beobtained by providing two different applications at the same location.Listed below in Table I are the power settings (peak power) and timeduration settings for different diopter corrections (-d), wherein thelocations (Loc) are the number of denatured areas in the cornea anddots/Loc is the number of power applications per location.

                  TABLE I                                                         ______________________________________                                        -d      DOTS/LOC  LOC      PWR (W)                                                                              TIME (SEC)                                  ______________________________________                                        1.5     1         8        0.66   .75                                         2.5     2         8        0.66   .75                                         3.5     2         8        0.83   .75                                         4.5     2         16       0.66   .75                                         6.0     2         16       0.83   .75                                         ______________________________________                                    

Using the parameters listed in Table I, the procedure of the presentinvention was performed on 36 different patients suffering from somedegree of hyperopia. A pattern of 8-16 denatured areas were created inthe non-vision area of the eye. Patients who needed higher dioptercorrections were treated with high applications of power. FIG. 1b showsthe amount of regression in the vision correction of the eye. The eyeswere initially overcorrected to compensate for the known regression inthe procedure. As shown in FIG. 1b, the regression became stabilizedafter approximately 60 days and completely stabilized after 180 days.The error in overcorrection was within +/-0.5 diopters.

FIG. 1c shows nominal thermal profiles produced by the application ofpower to the cornea. As known to those skilled in the art, the corneaincludes an epithelium layer, a Bowmans membrane, a stroma, a Descemetsmembrane and a endothelium layer. Without limiting the scope of thepatent, the applicant provides the following discussion on the possibleeffects of the present method on the cornea of the eye. When power isfirst applied to the cornea the current flows through the center of thetissue immediately adjacent to the probe tip. The application of powercauses an internal ohmic heating of the cornea and a dehydration of thetissue. The dehydration of the tissue rapidly increases the impedance ofthe local heated area, wherein the current flows in an outward mannerindicated by the arrows in FIG. 1c. The cycle of dehydration and outwardcurrent flow continues until the resistance from the tip to the outerrim of the corneal surface, and the full thermal profile, issignificantly high to prevent further current flow of a magnitude tofurther cause denaturing of the corneal tissue. The direct contact ofthe probe with the cornea along the specific power/time settings of thepower source creates a thermal profile that denatures both the Bowman'smembrane and the stroma. The denaturing of both the Bowman's membraneand the stroma in a circular pattern creates a linked belt typecontracted annular ring. This annular ring will create a steepening ofthe cornea and sharpen the focus of the images on the retina. To controland minimize the denatured area, the surface of the eye is kept dry byapplying either a dry swab to the cornea or blowing dry air or nitrogenacross the surface of the eye.

The design of the power source and the high electrical resistance of thedenatured area provides a self limit on the amount of penetration andarea of denaturing of the cornea. Once denatured, the cornea provides ahigh impedance to any subsequent application of power so that arelatively low amount of current flows through the denatured area. Ithas been found that the present procedure has a self limited denaturedprofile of approximately no greater than 75% of the depth of the stroma.This prevents the surgeon from denaturing the eye down to the decemetsmembrane and endothelium layer of the cornea.

FIG. 1c shows nominal thermal profiles for diopter corrections of -1.5d, -2.5-3.5 d and -4.0-6.0 d, respectively. In accordance with Table I,a -1.5 diopter correction creates a denatured diameter of approximately1 mm and a stroma penetration of approximately 30%. A -2.5-3.5 dcorrection creates a denatured diameter of approximately 1.13 mm and astroma penetration of approximately 50%. A -4.0-6.0 d correction createsa denature diameter of approximately 1.25 mm and a stroma penetration ofapproximately 75%.

FIGS. 2-5 show an embodiment of the probe 12. The probe 12 has a firstelectrode 30 and a second electrode 32. Although two electrodes aredescribed and shown, it is to be understood that the probe may haveeither both electrodes (bipolar) or just the first electrode (unipolar).If a unipolar probe is used, a return electrode (indifferent electrode)is typically attached to, or held by, the patient to provide a "return"path for the current of the electrode.

Both electrodes 30 and 32 extend from the hand piece 16 which contains apair of internal insulated conductors 34 that are contact with theproximal end of the electrodes. The first electrode 30 has a tip 36which extends from a first spring member 38 that is cantilevered fromthe hand piece 16. The electrode 30 is preferably constructed from aphosphor-bronze or stainless steel, wire or tube, that is 0.2-1.5 mm indiameter. The spring portion 38 of the first electrode 30 is preferably50 millimeters (mm) long. In one embodiment, the tip 36 has an includedangle of between 15°-60°, 30° nominal, and a nose radius ofapproximately 50 microns. A majority of the electrode 30 is covered withan insulating material to prevent arcing, and to protect non-targettissue, the user and the patient. The relatively light spring force ofthe probe provides a sufficient electrode pressure without penetratingthe cornea.

The second electrode 32 includes a disk portion 40 which extends from asecond spring member 42 that is also cantilevered from the hand piece16. The disk portion 40 is spaced a predetermined distance from firstelectrode 30 and has an aperture 44 that is concentric with the tip 36.In the preferred embodiment, the disk portion 40 has an outer diameterof 5.5 mm and an aperture diameter of 3.0 mm. The disk 40 further has aconcave bottom surface 46 that generally conforms to the shape of thecornea or sclera.

In one embodiment, the bottom surface 46 has a spherical radius ofapproximately 12.75 mm and a griping surface to assist in the fixationof the eye. The second electrode 32 provides a return path for thecurrent from the first electrode 30. To insure proper grounding of thecornea, the surface area of the disk 40 is typically 20-500 times largerthan the contact area of the tip 36. In the preferred embodiment, thesecond spring member 42 is constructed to have a spring constant that isless than one-half the stiffness of the first spring member 38, so thatthe second electrode 32 will have a greater deflection per unit forcethan the first electrode 30. As shown in FIG. 3, the tip 36 and disk 40are typically located at angles a' and a" which may range between30°-180°, with the preferred embodiment being 45°. As shown in FIG. 5,the probe 12 is pressed against the cornea to allow the second electrode32 to deflect relative to the first electrode 30. The second electrode32 is deflected until the tip 36 is in contact with the cornea.

For surgeons who prefer "two handed" procedures, the probe could beconstructed as two pieces, one piece being the first electrode, and theother piece being the second electrode which also stabilizes the eyeagainst corneal movement. Although the probe has been described andshown denaturing a cornea, it is to be understood that the probes andmethods of the present invention can be used to denature other tissuesto correct for wrinkles, incontinence, etc. For example, the probe couldbe used to shrink a sphincter to correct for incontinence. The techniquewould be basically the same with small closely spaced dots forming atightening line, belt or cylinder.

FIG. 6 shows a pattern of denatured areas 50 that have been found tocorrect hyperopic conditions. A circle of 8 or 16 denatured areas 50 arecreated about the center of the cornea, outside the visual axis portion52 of the eye. The visual axis has a nominal diameter of approximately 5millimeters. It has been found that 16 denatured areas provide the mostcorneal shrinkage and less post-op astigmatism effects from theprocedure. The circle of denatured areas typically have a diameterbetween 6-8 mm, with a preferred diameter of approximately 7 mm. If thefirst circle does not correct the eye deficiency, the same pattern maybe repeated, or another pattern of 8 denatured areas may be createdwithin a circle having a diameter of approximately 6.0-6.5 mm either inline or overlapping. It has been found that overcorrected hyperopicconditions may be reversed up to 80% by applying a steroid, such ascortisone, to the denatured areas within 4 days of post-op and continuedfor 2 weeks after the procedure. The procedure of the present inventioncan then be repeated after a 30 day waiting period.

The exact diameter of the pattern may vary from patient to patient, itbeing understood that the denatured spots should preferably be formed inthe non-visionary portion 52 of the eye. Although a circular pattern isshown, it is to be understood that the denatured areas may be located inany location and in any pattern. In addition to correcting forhyperopia, the present invention may be used to correct astigmaticconditions. For correcting astigmatic conditions, the denatured areasare typically created at the end of the astigmatic flat axis. Thepresent invention may also be used to correct radial keratotomyprocedures that have overcorrected for a myopic condition.

The probe and power settings have been found to create denatured areasthat do not reach the Decemets membrane. It has been found thatdenatured areas of the Bowmans layer in the field of vision may disturbthe patients field of vision, particularly at night. The presentinvention leaves a scar that is almost imperceptible by slit lampexamination 6 months after the procedure. It has been found that thedenatured areas generated by the present invention do not produce thestar effect caused by the refraction of light through the slits createdin a corrective procedure such as radial keratotomy.

FIG. 7 shows an alternate embodiment of a probe 60 which has a pluralityof first electrodes 62 coupled to a cage 64. The cage 64 includes afirst ring 66 separated from a second ring 68 by a number of spacers 70.The cage 64 can be connected to a handle (not shown) which allows thesurgeon to more easily utilize the probe 60.

The first electrodes 62 extend through apertures 72 in the rings 66 and68. The electrodes 62 can move relative to the cage 64 in the directionsindicated by the arrows. The probe 60 has a plurality springs 74 locatedbetween the rings and seated on washers 76 mounted to the electrodes 62.The springs 74 bias the electrodes 62 into the positions shown in FIG.7. In the preferred embodiment, the probe 60 includes 8 electrodesarranged in a circular pattern having a 7.0 millimeter diameter.

In operation, the probe 60 is pressed onto the cornea so that theelectrodes 62 move relative to the cage 64. The spring constant of thesprings 74 is relatively low so that there is a minimal counterforce onthe tissue. A current is supplied to the electrodes 62 through wires 78attached thereto. The probe 60 is preferably used as a uni-polar device,wherein the current flows through the tissue and into a return electrodeattached to or held by the patient.

FIGS. 8a and 8b show a preferred method of correcting for hyperopicconditions using the electrode system of the present invention. As shownin procedural block 100 refractive readings are initially taken of botheyes with, and then without, cycloplasia. In procedure block 102, theinteroccular pressure and cornea thickness at the center of the eye aretaken with a tonometer and pacymeter, respectively. If the interoccularpressure is 20 mm Hg or greater, for I.O.P. reduction, 1 drop of a 0.5%solution marketed under the trademark "Betagan" is applied to the corneatwice a day for 2-3 months and then initial test are repeated. Atopography reading of the eye is then taken to determine the shape ofthe cornea in procedural block 104.

Approximately 30 minutes before the application of the electrode, thepatient is given a mild tranquilizer such as 5 mg of valium, and thesurgeon administers drops, such as the drops marketed under thetrademark "Madryacil", to dilate the pupil and freeze accommodation, inblock 106. Immediately before the procedure, 2 drops of a topicalcocaine commonly known as "Proparacaine" is administered to the eyes inblock 108. In block 110 an in line microscope light is directed to thecornea for marking purposes. Then the lighting may be directed in alateral direction across the cornea. Laterally lighting the eye has beenfound to provide good visualization without irritating or photobleachingthe retina.

In procedural block 112, the surgeon marks 8 or 16 spots on the cornea,wherein the pattern has a preferred diameter of approximately 7 mm. Thesurgeon sets the power and duration setting of the power unit to theproper setting. In block 114, the surgeon then places the tip at one ofthe spot markings and depresses the foot switch of the system, so thatpower is supplied to the probe and transferred into the cornea. Thisprocess is repeated at all of the spot markings. The epithelium of thedenatured areas are then removed with a spatula in block 116. If adiopter correction of -2.5-3.5 d, or -4.0-6.0 d is required the tip isagain placed in contact with the spots and power is applied to thecornea to generate a deeper thermal profile in the stroma. The procedureis then checked with an autorefractor.

The eyes are covered with a patch or dark glasses, and the patient isgiven medication, in block 118. The patient preferably takes anantibiotic such as a drug marketed under the trademark "Tobrex" every 2hours for 48 hours, and then 3 times a day for 5 days. The patient alsopreferably takes an oral analgesic, such as a drug marketed under thetrademark "Dolac", 10 mg every 8 hours for 48 hours and a drug marketedunder the trademark "Globaset" every 8 hours for 48 hours. If thepatient has been overcorrected, the procedure can be reversed by waiting3-4 days after the procedure and then administering to the eyes 1 dropof a steroid such as cortisone, 3 times a day for 1-2 weeks.

FIG. 9 shows a pattern of denatured areas 130 combined with a pattern ofincisions 132 that can correct myopic conditions. The incisions can bemade with a knife or laser in accordance with conventional radialkeratotomy procedures. The incisions are made from a 3.5 mm diameter towithin 1 mm of the limbus at a depth of approximately 85% of the cornea.Denatured areas are then created between the incisions 132 using theprocedure described above. The power unit is preferably set at 0.75 W ofpower and a time duration of 0.75 seconds. The slow heating of thecornea is important for minimizing regression, and as such 0.75 secondshas been found to be a preferable time duration to account for thepatients fixation ability and the surgeons reaction time. The denaturedareas pull the incisions to assist in the reshaping of the cornea. Thisprocedure has been found to be effective for diopter corrections up to+10.0 d. Penetrating the cornea only 85% instead of conventionalkeratotomy incisions of 95% reduces the risk of puncturing the decemetsmembrane and the endothelium layer. This is to be distinguished fromconventional radial keratotomy procedures which cannot typically correctfor more than 3.5 diopters.

The denatured pattern shown in FIG. 6 has been shown to correct up to7.0 diopters. As shown in FIG. 10, a circumferential pattern ofincisions 134 may be created in addition to a pattern of denatured areas136, to increase the correction up to 10.0 diopters. The incisions willweaken the eye and allow a more pronounced reshaping of the eye. Thepattern of incisions may be created at either a 6 mm diameter or a 8 mmdiameter. The incisions typically penetrate no greater than 75% of thecornea. The contractive forces of the denatured areas may create gaps inthe incisions. It may be preferable to fill the gaps with collagen orother suitable material.

FIG. 11 shows an alternate embodiment of a probe which has a singleelectrode 140. The electrode 140 has a tip 142 which is preferably 0.009inches in diameter. The tip extends from a spring beam 144 that is bentso that the surgeon can place the tip onto the cornea over nose and browwithout impairing the surgeon's vision. The spring beam 144 ispreferably insulated and is 0.2-1.5 mm in diameter. The spring beam 144extends from a base 146 that is inserted into the hand piece. The base146 is preferably constructed from stainless steel and is 0.030-0.125inches in diameter, with a preferred diameter of 0.060-0.095 inches.

As shown in FIG. 11a, the end of the tip 142 is preferably flat and hasa textured surface 148. The textured surface 148 slightly grips thecornea so that the tip does not move away from the marking when power isapplied to the eye.

As shown in FIG. 12, the probe 200 has a return electrode lid speculum202 that maintains the eye lid in an open position. The speculum 202 hasa pair of cups 204 located at the end of wire 206. The cups 204 areplaced under an eye lid and maintain the position of the lid during theprocedure. Extending from the lid speculum 202 is a wire 208 that istypically plugged into the unit 14 "return" connector. It has been foundthat the procedure of the present invention will produce more consistentresults when the probe 200 uses the lid speculum 202 as the returnelectrode. The impedance path between the probe 200 and the lid speculum202 is relatively consistent because of the relatively short distancebetween the lid speculum 202 and the probe 200, and the wet interfacebetween the cornea and the lid speculum 202.

FIGS. 13-15 show alternate probe tip embodiments. The tips have stepsthat increase the current density at the corneal interface. The tips arepreferably constructed from a stainless steel that is formed to theshapes shown. The tip 220 shown in FIG. 13 has a cylindrical step 222that extends from a base 224. The step 222 terminates to a point,although it is to be understood that the end of the step 222 may have aflat surface. In the preferred embodiment, the base 224 has a diameterof 350 microns (um), and the step 222 has a diameter of 190 microns anda length of 210 microns.

The tip 230 shown in FIG. 14, has a first step 232 extending from a baseportion 234 and a second step 236 extending from the first step 232. Theend of the second step 236 may be textured to improve the contactbetween the probe and the cornea. In the preferred embodiment, the firststep 232 has a diameter of 263 microns and a length of 425 microns, thesecond step 236 has a diameter of 160 microns and a length of 150microns. The tip 240 shown in FIG. 15, has a first step 242 that extendsfrom a base portion 244 and a second tapered step 246 that extends fromthe first step 242. In the preferred embodiment, the first step 242 hasa diameter of 290 microns and a length of 950 microns. The second step246 has a diameter of 150 microns, a length of 94 microns and a radiusof 70 microns.

FIGS. 16 and 17 show alternate probe tip embodiments which have an outerelectrode concentric with an inner electrode. The electrodes are coupledto the unit so that the electrodes can provide current to the corneaeither simultaneously or sequentially. By way of example, it may bedesirable to initially apply power to the cornea with the innerelectrode and then apply power with the outer electrode, or apply powerwith both electrode and then apply power with only the outer electrode.Assuming the same current value, the inner electrode will apply powerwith a greater current density that the outer electrode. The dualelectrode probes allow the surgeon to create different thermal profiles,by varying the current densities, waveforms, etc. of the electrodes.

The probe 250 shown in FIG. 16 has an inner electrode 252 that isconcentric with an intermediate layer of insulative material 254 and anouter conductive layer 256. In the preferred embodiment, the innerelectrode 252 may have a diameter of 125 microns and extend from theouter layers a length of 150 microns. The outer layer 256 may havediameter of 350 microns. The inner electrode 252 may be capable of beingretracted into the insulative layer 254 so that the inner electrode 252is flush with the outer electrode 256, or may be adjusted between flushand full extension, either manually or under servo control.

FIG. 17 shows another alternate embodiment, wherein the probe 260 has anadditional outer sleeve 262. The sleeve 262 has an internal passage 264that supplies a fluid. The fluid may be a gas that stabilizes thecurrent path to the cornea or a relatively high impedance solution (suchas distilled water) which provides a coolant for the eye.

FIG. 18 shows an economical detachable probe 270 embodiment. The probetip 270 has a conductive wire 272 that is located within a plastic outerhousing 274. The probe tip 270 has a flexible section 276 that extendsfrom a body 278, preferably at a 45° angle. The tip 280 extends from theflexible section 276, preferably at a 90° angle. Extending from theopposite end of the handle 278 is a male connector 282. The connector282 may have a conductive sleeve 284 that is inserted into the socket286 of a female probe connector 288. The end of the wire 272 may bepressed between the inner surface of the sleeve 284 and the outersurface of the male connector 282 to provide an electrical interconnectbetween the tip end 280 and the female probe connector 288. The sleeve284 may have a detent 290 to secure the probe tip 270 to the probeconnector 288. The probe tip end 280 may have distal shapeconfigurations similar to the tips shown in FIGS. 11, 13, 14, 15, 16, or17.

FIG. 19 shows a circuit 300 that will prevent the use of the probe tipbeyond a predetermined useful life. The circuit 300 has a plurality offuses 302 that are blown each time the probe is used for a procedure.The probe is rendered inoperative when all of the fuses 302 are blown.The circuit 200 typically has 10-30 fuses 302, so that the probe canonly be used 10-30 times. The circuit 300 (not shown) is preferablylocated on a printed circuit board (not shown) mounted to the probe. Thefuses 302 may be covered with a flash inhibitor such as silica sand toprevent fuse alloy splatter/spray when the fuses are blown.

In the preferred embodiment, the fuses 302 are connected to drivers 304that are coupled to a plurality of serial to parallel shift registers306. The clock pin (CLK) pins and input pin D of the first shiftregister are connected to the unit 14. The unit 14 initially provides aninput to the first shift register and then shifts the input through theregisters 306 by providing a series of pulses on the clock pin CLK. Anactive output of a register 306 will enable the corresponding driver 304and select the corresponding fuse 302. The unit 14 may clock the inputthrough the shift registers 306 in accordance with an algorithmcontained in hardware or software of the unit, wherein each clock signalcorresponds to the end of a procedure. By way of example, a clock signalmay be generated, and a fuse blown, upon the occurrence of four shotsthat have a power greater than 0.16 W and a duration greater than 0.25seconds.

The circuit 300 may have a separate sample unit 308 that is coupled tothe unit 14 and the fuses 302. The sample unit 308 may have an opticalcoupler 310 which isolates the unit 14 from power surges, etc. or may beany voltage or current threshold/comparator circuitry known in the art.The sample unit 308 may have a relay 312 that closes a switch when thefuses 302 are to be sampled. The sample circuit 308 samples the fuses302 to determine how many fuses 302 are not blown. The number ofremaining fuses 302, which correlate to the amount of procedures thatcan be performed with that particular probe, may be provided by adisplay on the unit 14. By way of example, after sampling the fuses, theunit 14 may display the number 6 providing an indication that 6 moreprocedures can be performed with the probe. A 0 on the display mayprovide an indication that the probe must be replaced.

To sample the fuses 302, the unit 14 sets relay 312 to "sample" andclocks an input through the registers 306. If the fuse 302 is not blownwhen the corresponding driver 304 is enabled by the output of theregister, the optical coupler 310 will be enabled. If the fuse 302 isblown the optical coupler 310 will not be enabled. The process ofenabling a driver 304 and monitoring the output of optical coupler 310is repeated for each fuse 302. The unit 14 counts the number of viablefuse links remaining to determine the remaining useful lifes of theprobe.

While certain exemplary embodiments have been described and shown in theaccompanying drawings, it is to be understood that such embodiments aremerely illustrative of and not restrictive on the broad invention, andthat this invention not be limited to the specific constructions andarrangements shown and described, since various other modifications mayoccur to those ordinarily skilled in the art.

What is claimed is:
 1. A thermokeratoplastic probe system for reshapinga cornea, comprising:a power source which contains a radio frequencygenerator that generates an alternating current; a first electrode thatis coupled to said radio frequency generator and which transfers thealternating current from said radio frequency generator to the corneawhich is in contact with said first electrode; a lid speculum that iscoupled to said power source and the cornea to create a return path sothat the alternating current flows from said first electrode, throughthe cornea and back into said lid speculum.
 2. The system as recited inclaim 1, wherein said lid speculum is coupled to said power source by awire.
 3. The system as recited in claim 1, wherein said first electrodehas a tip which has a first step portion that extends from a baseportion, said first step portion having a diameter greater than one-halfa diameter of said base portion.
 4. The system as recited in claim 3,wherein said first step has a point.
 5. The system as recited in claim3, wherein said first step has a flat end.
 6. The system recited inclaim 3, wherein said first electrode has a second step portion thatextends from said first step portion, said second step portion having adiameter greater that one-half of said dimension of said first stepportion.
 7. The system as recited in claim 1, wherein said firstelectrode is separated from a second electrode by an outer layer ofinsulative material.
 8. The system as recited in claim 7, wherein saidfirst electrode extends beyond said second electrode.
 9. The system asrecited in claim 7, wherein said second electrode separates said firstelectrode from an outer sleeve which has an internal fluid passage. 10.A thermokeratoplastic probe that is coupled to a source of power,comprising:an electrode coupled to the source of power; a fuse coupledto said electrode, said fuse preventing power from being supplied tosaid electrode when said fuse is blown; and, an electrical circuit thatprovides a fuse current to blow said fuse after power is supplied tosaid electrode.
 11. The probe as recited in claim 10, further comprisinga sample unit which samples a plurality of fuses to determine how manyfuses are in the open condition.